Series America: Equity and Equality in Health 1 Inequality and the health-care system in the USA Samuel L Dickman, David U Himmelstein, Steffie Woolhandler Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. Lancet 2017; 389: 1431–41 The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a See Editorial page 1369 Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based See Comment pages 1376 disparities in health, instead often exacerbates them. Other articles in this Series address population health and 1378 inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans This is the first in a Series of have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage five papers about equity and equality in health in the USA expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have Department of Medicine, undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health- University of California, care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, San Francisco, CA, USA from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of (S L Dickman MD); City medical care borne by non-wealthy Americans. University of New York School of Urban Public Health at Hunter College, New York, NY, 5 Introduction research by the economists Piketty and Saez that USA (Prof D U Himmelstein MD, As economic inequality in the USA has deepened, so too revealed levels of income inequality unrivalled since the Prof S Woolhandler MD); and has inequality in health. Almost every chronic condition, stock market bubble of the 1920s. The share of total Harvard Medical School, Boston, MA, USA from stroke to heart disease and arthritis, follows a income going to the top 1% of earners has more than (Prof D U Himmelstein, 6 predictable pattern of rising prevalence with declining doubled since 1970 (figure 1), while most workers in the Prof S Woolhandler) 1 7 income. The life expectancy gap between rich and poor USA have experienced slow income growth. As Correspondence to: Americans has been widening since the 1970s,2 with the measured by the Gini coefficient, a standard metric of Prof David U Himmelstein, City difference between the richest and poorest 1% now income inequality, the USA is now more unequal than all University of New York School of Urban Public Health at Hunter standing at 10·1 years for women and 14·6 years for but three other countries (Chile, Mexico, and Turkey) in College, NY 10035, USA 3 men. The health of poor communities is often neglected: the Organization for Economic Co-operation and [email protected] for example, in Flint (MI, USA), a de-industrialised, Development (OECD). The most equal countries are See Online for infographic impoverished, and predominately African-American city, Denmark, Slovenia, Norway, and Slovakia. www.thelancet.com/ public officials dismissed evidence that children were The surge in top incomes has magnified inequality in infographics/us-health being exposed to toxic levels of lead in the city’s drinking wealth (ie, assets). Since 1986, the top 0·1% of households water for several months.4 (those with assets exceeding US$20 million) has Attention to economic inequality intensified after the Occupy Wall Street movement decried the rising wealth and power of the richest 1%. This movement popularised Key messages • Economic inequality in the USA has been increasing for decades and is now among the highest in developed countries. Search strategy and selection criteria • Differences in life expectancy have been widening, with the wealthiest Americans now We searched PubMed and Google Scholar using the following living 10–15 years longer than the poorest. terms: “health care quality” OR “quality of care” AND “primary • Despite coverage gains from the Affordable Care Act, about 27 million Americans care” OR “specialty care” OR “specialist” OR “hospital” OR remain uninsured—a number that is likely to increase under the reforms advocated by “surgery” OR “cancer” OR “outpatient” AND “inequality” OR Republicans now empowered in Washington, DC. “unequal” OR “disparities” AND “US” OR “United States”; • Both overall and government health spending are higher in the USA than in other “access to care” OR “health care access” OR “barriers to care” countries, yet inadequate insurance coverage, high cost sharing by patients, and AND “inequality” OR “unequal” OR “disparities” AND “poor” geographical barriers restrict access to care for many. OR “poverty” OR “wealthy” OR “income” AND “US” OR • Financing of health care in the USA is regressive, with poor and middle-class “United States”; “regressive” OR “progressive” AND “health individuals paying a larger share of their incomes for care than the affluent, thereby financing” OR “health finance” OR “out of pocket”; and deepening inequalities in disposable income. “medical bankruptcy” OR “medical debt”. Our search included • Rising insurance premiums for employer-sponsored private coverage have eroded articles focusing on the USA published in English between wage gains for middle-class Americans. Jan 1, 2011, and March 31, 2016, prioritising recent research. • Medical indebtedness is common among both insured and uninsured Americans, and We identified additional sources, including important older often leads to bankruptcy. manuscripts, from the reference lists of selected articles and • To achieve health-care equality, a non-market financing scheme that treats health care from consultation with expert colleagues. as a human right is essential. www.thelancet.com Vol 389 April 8, 2017 1431 Series 20 middle-class families have been bankrupted by illness and medical bills.14 Meanwhile, very wealthy Americans are turning to so-called concierge practices that offer lengthy office visits and unfettered access to specialists. This Series paper examines how the health-care system 15 in the USA contributes and responds to inequality. We focus our attention on the association between inequality and the medical care system. total income (%) of We first review how social position influences 10 Americans’ access to medical services and the quality of Share those services. The uninsured face the greatest barriers to care, but many insured Americans are also unable to afford medical care because of cost sharing. Although race-based disparities in quality are well documented, the 5 5 0 5 0 low quality scores of doctors and hospitals serving poor 1910 1915 1920 1925 1930 193 1940 1945 1950 1955 196 196 1970 1975 1980 1985 1990 1995 200 2005 2010 2015 communities might reflect patients’ deprived social Year circumstances rather than their providers’ performance. Figure 1: Share of total income received by the top 1% of earners in the USA, 1913 to 2014 We also review how the health-care costs borne by Source: Saez (2016).6 Income is defined as pre-tax market income excluding capital gains and government households—in the form of insurance premiums, taxes, transfers. In 2014, the top 1% included families with annual incomes above $387 810, who collectively received 18% of total income in the USA. and out-of-pocket payments—exacerbate income inequality, forcing many Americans to cut back on food accumulated nearly half of all new wealth, and now and other necessities, and contributing to most personal controls as much wealth as the bottom 90%, whose share bankruptcies. We conclude by discussing the historical has fallen steadily.8 context for today’s health-care inequalities, and propose Wealth inequality between racial and ethnic groups in options for reform. the USA is especially striking, and is several times greater than income inequality. In 2013, median family Inequality and access to care wealth for the non-Hispanic white population was ten Income-related disparities in access to care are far wider times that of Hispanics and more than 12 times that of in the USA than in other wealthy countries.15 Before the African-Americans.9 The racial wealth gap results from 2010 passage of the ACA, which progressively expanded historical factors dating back to slavery—many of which health insurance coverage, 39% of Americans with persist—including legalised racial segregation in the pre- below-average income reported not seeing a doctor for a civil rights era, pervasive job and housing discrimination, medical problem because of cost, compared with 7% of exclusionary city zoning laws, unequal education, and low-income Canadians and 1% of those in the UK.16 inheritance laws that perpetuate past inequalities.10 Inequality in access to care is particularly stark in Although top incomes have risen, so has extreme Southern states. For example, in Texas, Mississippi, and poverty. More than 1·6 million households in the USA, Florida, adults on a low income are more than twice as including 3·5 million children, survive on incomes of likely to face cost-related barriers to care as their less than $2 per person per day—WHO’s definition of counterparts in Maine (a relatively poor New England extreme poverty; this number has more than doubled state) and Massachusetts.17 since the 1990s.11 Disparities in access are largely due to high rates of The health-care system could soften the effects of uninsurance or inadequate health insurance among low- economic inequality by delivering high-quality care to all. income Americans, although Americans with above- Yet the institutions and financing patterns of the health- average incomes probably also have worse access to care care system in the USA—by far the world’s most than do their peers in other countries.16 Today, despite gains expensive12–cause it to fall short of this ideal.